Pre-Consultation Health Questionnaire
Please complete this preliminary questionnaire to provide us with some basic information about your health goals in order to make the best use of our time together. We would be grateful if you could return this to us no later than 24 hours before your appointment. All information that you provide is strictly confidential.
Full name
Date of birth
*
Gender
Male
Female
Country of residence
Address
*
Postcode
*
Phone
*
Email
*
Occupation
Describe your work environment (e.g. office, outdoor)
Health Goals
What are your main reasons for seeking nutritional advice?
*
What outcome(s) do you wish to achieve?
*
Please list the health problems(s) you would most like to focus on (including any relevant success or failures in management, onset dates and duration)
*
Have you had any recent health tests or blood tests (please include any important results)?
*
Have you had any other major surgery, diagnosed medical conditions, significant periods of ill health, or do you suffer from any other chronic health problems? (Please give details e.g. high blood pressure, frequent colds, recurrent urinary infections etc.)
*
Do you suspect your symptoms relate to a particular event or time in your life?
Medication
Please list anything you take regularly including GP prescribed medication, self-prescribed medication (e.g. painkillers) and things you buy over the counter including doses if possible
*
Nutritional And Herbal Supplements
Please list any nutritional supplements you are currently taking e.g. vitamins, minerals, protein powders, herbal or homeopathic remedies (including brand and doses if possible)
*
Your Vital Statistics
What is your normal blood pressure?
Your height?
Your current weight?
Are you happy with your current weight?
Yes
No
Is your weight
Increasing?
Decreasing?
Stable?
What is your waist circumference (if known)?
General Wellbeing and Lifestyle
How would you rate your general feeling of wellbeing during the last week on a scale of 0 (as bad as it could be) to 10 (as good as it could be)?
0
1
2
3
4
5
6
7
8
9
10
Have you had any recent stressful events such as bereavement, separation, moving house or changing jobs?
Do you work long or irregular hours?
Do you feel guilty when you are relaxing?
What do you do for relaxation?
Do you exercise regularly?
Each Day
Every Few Days
Weekly
Less Frequently
Rarely/Never
Do you sleep well?
Yes
No
Do you smoke (If so how many and for how long)?
Eating Habits
Describe your typical BREAKFAST
Describe your typical LUNCH
Describe your typical EVENING MEAL
Describe your typical daily SNACKS
Describe your typical DRINKING habits (Tea, Coffee, Soft Drinks, Juice, Water etc)
Do you drink alcohol?
Never
Rarely
Weekly
Daily
Do you have any known food allergies/intolerances? If so, please provide details.
Are you currently following any type of diet?
Is there any more information you would like to provide?
Please Check Your Email For Confirmation Of Submission After Submitting This Form
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